| NPI | 1508387176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WA A161199392) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: UT 11357098-4810) |
| Enumeration Date | 2017-07-04 |
| Last Update Date | 2022-09-01 |